Research for determinants of sick leave prescription for lowed back pain Results of a qualitative study Dr Martine Morvan CNAMTS

Background "The common lumbago corresponds to pain lumbar vertebrae of the adult unrelated to an inflammatory, traumatic, tumoral or infectious cause". [HAS-2005] The concept about the therapy for low back pain have changed : Bio-médical model  Bio-psycho-social model

Background The actual guidelines are: Reassure the patient Exclude the lumbago with red flags Evaluate the risk of chronicity (yellow flags les risques de chronicité (drapeaux jaunes) Treat the pain and help the patient to accept her Avoid the rest …… Prescribe the return to physic activity …….

Background What is the prevalence of lumbago among the motives of seak leave: 10,3% among all the seak leave received during one week in 03/2014 (n= 3074) 20.5% was linked at a professionnel context The duration was > 35 days for 38.8% Risk linked to long sick leave : negative effects on health , the sick leave being an independent factor from chronicity ,having a social impact and inducing important costs. No recommendation in France on the rules of prescription of sick leave for common lumbago except indicative duration of index cards marks of the Health insurance.

Objectives Objectives of the study: define the determinants of the prescription and the management of sick leave for lower back pain. Collect the ideas, beliefs and pratices about the prescription of seak leave Reseach the limited factors in coordination between the different actor Find some tracks action

Method Qualitative investigation by realization of 6 focuses group doctors between September and October, 2013 in 4 geographical ponds of the department of the Gard 80 doctors: general practitioners, rheumatologists, medical adviser and occupational doctors. The discussions were organized around 12 questions in three parts : Motives for sick leave prescription ? Coordination with other professionals? Ideas for improvement ? Practical solutions? Interviews recorded and transcribed (verbatim). Coding and analysis of verbatim data by 3 independent physicians

Results (1) Massive expression on the sense given to the sick leave: 50 % on the questions of the motivation of work stoppage, 37 % on the coordination and 13 % on the ideas of improvement. (Verbatim 1244) Main actors: the regular doctor (47 %) then the patient (14 %), Problems linked to the extension of work stoppage: less of 20% sur the initial sick leave Two main themes emerged from the analysis : The relationship between physician and patient (58%) The care pathway (42%)

What say the physicians ? Results (2) What say the physicians ? On the relationship between physician and patient. « On a quand même des patients qu’on connait depuis une dizaine d’année, on sait quand même voir » « Le malade nous dit "je travaille ça me fait mal" , donc notre rôle c’est de le soulager » « Quand le patient vient et qu’il demande il faut m’arrêter, c’est énervant. Ce n’est pas eux qui décident, on se sent forcé  ! » On the care pathway « … le délai des examens complémentaires, quelques fois impose de prolonger un arrêt de travail parce qu’il y a un scanner…» « quelqu’un qui est coincé on a envie de prendre un avis rhumato et on a beaucoup de mal à avoir un avis rapide ».

Results (3) Two sub-themes were necessary to classify all the verbatim: The determiners of the medical consultation : Clinical data, professional practices, beliefs of physicians and demands of the patient, Leading role (60 %) beliefs of the doctor or his professional practice among the emitted ideas. The motives of sick leave and especially of its extension: Social and occupational context, clinical factors, technical, professional and regulatory needs, among which the former represented 25%.

What say the physicians ? Results (4) What say the physicians ? About the motives of sick leave « Si c’est une lombalgie chez un travailleur manuel, ça risque d’être plus long à reprendre que quelqu’un qui travaille derrière un bureau » « c’est parce qu’il n’y a pas des facilités d’accès … Je ne sais pas comment joindre un médecin conseil et encore moins un médecin du travail » « moi je pense qu’à ce moment-là nous, on devrait avoir la possibilité de tirer un signal d’alarme… » About their beliefs « …ça me parait vraiment difficile de mettre des règles générales à des cas particuliers, c’est quand même chaque fois un cas particulier… » « combien de temps? je ne sais pas. Ca peut être une journée comme 5 ans » « C’est parce que je pense que c’est quand on n’arrive pas à maîtriser, on sent qu’on fait des arrêts des travail sans justification »

Discussion The determiners of the prescription of the sick leave Are multifactorial, Bring in numerous domains (knowledge, practices, relational, coordination ,regulatory) explaining the big interpersonal variability of the modalities of prescription among the different physician interviews. Can be integrated into a decision-making model.

Decisional model PATIENT PHYSICIAN Decision  Prescription Care Patient behaviour Physician beliefs Objective data Professional practices Others PHYSICIAN Regulatory needs Technical needs Professional needs Clinical data Therapy Socio professional context Care pathway Patient- physician relation ship Decision  Prescription Sick leave First or renewable sick leave- Work return

To conclude The prescription of sick leave related to acute or chronic lumbago is influenced by many factors : explaining i)the variability in patterns and leave times, ii) the low possibility of action of physician, Showing that the solution do not seem to depend on the need of information and training of doctors showing the necessity to improve the medical coordination focused on the patient and pointing out the need of new actions from institutions.

To conclude A first experimental answer of health insurance consists to facilitate the care pathway for workers in long sick leave by phone appropriate support of the patients and answer to requests of general practitioners. The physicians proposed a new slogan: “J’ai mal au dos , je vais au boulot “

Thanks for your attention Study carried out in the department of Gard (France) with the collaboration of Pr Dupeyron (Unity of rehabilitation -CHU of Nîmes), Mrs Bonche (CPAM du Gard) Dr Papinaud (ERSM Languedoc-Roussillon) Dr Cholley (DRSM Languedoc-Roussillon) Acknowlegements to all the participants.